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What is Provider Credentialing

What is Provider Credentialing: A Complete Guide

Provider Credentialing

The procedure of acquiring and authenticating (verifying) a doctor’s credentials is called Provider credentialing. Sometimes known as medical Provider credentialing (professional background and educational history). Credentialing ensures that professionals are qualified to offer patients the treatment they need and have the necessary credentials. Here we will explain what is Provider Credentialing.

Provider credentialing is a screening procedure that healthcare facilities and health insurance companies use to confirm a provider’s credentials, practice, and experience. Before practicing on-site, all clinicians requesting clinical privileges must complete the credentialing process. It is also called medical credentialing. Traditional process of healthcare credentialing services is lengthy, which may take three months to complete.

Provider Credentialing and Insurance

Credentialing, sometimes known as “getting on insurance panels,” can be difficult and time-consuming; there is no one-size-fits-all method.

While the web portals for Medicare, DME (Durable Medical Equipment), and Medicaid allow for Provider credentialing, most insurance payers have their credentialing procedures.

Additionally, the majority of commercial insurance payers need recertification every few years. Medicare requires revalidation every five years, DMEPOS suppliers every three years, and some states’ Medicaid programs every year. 

Most insurance companies place time restrictions on resubmitting claims after an initial denial. You may encounter even more difficulties if the patient has secondary insurance. The longer you wait, the more probable it is that you won’t be able to collect the total amount (or any amount) from the insurance payer.

Provider Credentialing and Medical Practice

What is Provider Credentialing

Medical credentialing companies ensure all employees, applicants, and linked providers have the qualifications to carry out their responsibilities appropriately. In the healthcare sector, credentialing is how confidence is built, but the manual, paper-based procedure that is so common may be very time-consuming, error-prone, and expensive. Because of this, a lack of consistency over time may gradually cause that trust to decline. It can firmly establish trust throughout locations by utilizing technology to streamline the medical provider credentialing process.

The credentialing procedure for providers is essential for the health and safety of patients since it serves as the cornerstone for developing trust among the major players in the healthcare business. In this article, we will examine Provider credentialing in more detail, the data collected to credential a healthcare provider, and why leveraging trust as technology may be beneficial in increasing performance. 

Credentialing helps the medical industry with quality assurance by certifying that all doctors are practicing at the same level of care and offering legal clinical services. Just doctors competent to treat patients with insurance are allowed access, protecting not only the patients’ safety but also the wellbeing of the medical industry.

By using medical credentialing, contracted third parties can pay for medical practices on time and with the correct information. Reputable medical clinics can see an uptick in patients and, consequently, a rise in revenue. Due to simpler payment alternatives and excellent patient bases, medical credentialing is crucial for successful medical practices.

 The Role of Provider Credentialing

It can be challenging to understand what is Provider credentialing and the value of credentialing in healthcare, in contrast to the continual training healthcare practitioners receive every year. A significant portion of the medical credentialing procedure involves submitting numerous forms of paperwork. It could consume a significant amount of time and interfere with patient care. However, it serves as the cornerstone of contemporary healthcare.

One whose credentials are in order has been confirmed as a doctor or nurse who has undergone the necessary training, been certified by an impartial organization, and demonstrated that they possess the expertise required to deliver the best healthcare. So, without rigorous medical credentialing, the healthcare sector lacks control and has no assurance of standards or quality.

Quality Assurance 

The medical credentialing process provides quality assurance for the healthcare sector. It acts as a form of industry evaluation and ensures that the medical community’s quality standards are consistently met for the benefit of patients. Insurance companies frequently choose physicians and practices who have established their expertise in the relevant fields to reduce costs. 

Ensure Patient Safety

Credentialing safeguards patient safety by ensuring that hospitals and doctors have the training and experience necessary to serve patients. The method helps to reduce the likelihood of medical mistakes caused by unqualified professionals—Credentialing assists in reestablishing patient and medical practice trust, given all of this prior knowledge. When patients are convinced that their doctors have the qualifications and worth to act as their preferred healthcare providers, they can have complete faith in their ability. 

Avoid Revenue Losses

 With the proper credentials, delayed or refused reimbursements can be avoided without costing thousands of dollars in lost revenue. Inadequate credentialing or mistakes committed throughout the process may cause insurance companies to withhold payment from medical practitioners for their services. The insurance carrier may be entitled to pay for the operations in the past if a medical practice allows a doctor to treat patients before or during the credentialing process.

Expand your Clientele

Provider credentialing allows medical practices access to patient bases that were previously inaccessible to them since it permits practices to accept patients with health insurance benefits.

Enhance the Reputation of your Practice

More patients than ever before do their homework before selecting a physician or healthcare facility. It can be similar to looking into their background or reading internet patient reviews. Obtaining medical credentials is one of the best ways to enhance your online reputation. When potential patients study your medical practice, credentials give them the idea that it is well-established, reputable, and worthy of their trust.

Improve the Hiring Process

A thorough assessment considers a physician’s residency history, educational background, job experience, and other qualifications required when applying for benign certification. This procedure can determine whether a medical professional is qualified to carry out the activities specified in the job description if your medical practice recruits them. 

Provide a Competitiveness

Medical practices must discover strategies to distinguish themselves from the crowded healthcare industry—providers credentialing shows prospective patients that the practitioners in your medical group have training in their specialties. 

These physicians are more likely to join a practice with credentials and a sizable patient population than one without. The process of obtaining medical credentials puts your medical practice at a competitive advantage over companies outside your target market and encourages continued growth.

Provider Credentialing Process

Verifying provider credentials confirms that the providers hold all essential licenses and permits. Additionally, the credentialing organization ensures there was no problem indicating the practitioners cannot handle patients expertly. Here are a few places where we are explaining what is provider credentialing process.

The medical sector and insurance firms in the USA frequently work with other businesses to gather and authenticate the data. It’s credentialed verification organizations (CVOs). The healthcare industry regularly hires CVOs to enable more effective credentialing.

The process of credentialing and enrolling providers involves multiple steps. Each health plan a provider wants to join must go through this process.

Provider Credentialing Steps

  • Create a list and gather all the data you require for provider credentialing applications, including professional licenses, employment history (cv or resume), certificates, malpractice insurance, references, practice ownership information, W-9, background checks, bank records, and more.
  • Obtain the Provider’s National Provider Identification (NPI), Federal Tax ID, and Practice EIN (these must correspond to the information on the W-9 form for the Provider).
  • Obtain the Provider’s CAQH ID and register them with the organization. Verify that the Provider’s malpractice certificate and W-9 are current with CAQH. Verify the “month/year” formatting of the work and educational dates. CAQH will reject the application if you do not provide valid dates. Additionally, CAQH will email the Provider every three months to “re-attest” that the information in the profile is accurate; always respond promptly.
  • Verify whether processing the credentialing request requires the Provider’s original handwritten signature.
  • Fill out and submit several applications with each insurance provider.
  • Obtain a “reference number” from the insurance payer as soon as you’ve finished the initial credentialing evaluation, and record it in your credentialing tracking records.
  • Follow up with insurance payers to find out the Provider’s credential application status. If something is missing from the application, they are infamous for not returning calls. Keep track of every online or telephone follow-up during the credentialing procedure.
  • Ensure that the payer data is up to date in your billing system: Enrollment in Electronic Data Interchange (EDI).
  • Before you sign the credentialing contract with the insurance payer, review the fee structure. It could be necessary to ask for a price schedule and give the payer your top 20 billing codes.
  • Save copies of any contracts, credentialing applications, and enrollment letters you submit and get from the insurance payer.

 Final Thoughts

Clients frequently claim that they cannot afford to outsource the process of credentialing doctors. Still, after examining the cost of handling the procedure internally, they discover that outsourcing saves the company money. When you outsource your medical Provider credentialing to a team of professionals, your team may be credentialing one or two (or twenty) providers at a time. Still, our team is credentialing dozens of providers at once, every single day. Thus, at BMB, we may merge processes to cut costs and time. Clients frequently claim that they cannot afford to outsource the process of credentialing doctors, but after examining the cost of handling the procedure internally, they discover that outsourcing saves the company money.

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